States have an increasing interest in extending Medicaid coverage from 60 days to 12 months postpartum, driven by states’ priorities for ensuring continuity of coverage and addressing the maternal mortality crisis. To extend this coverage, states can request approval from the Centers for Medicare and Medicaid Services (CMS) under Medicaid Section 1115 demonstrations. Through a new provision included in the American Rescue Plan Act (ARPA), states can now also extend postpartum coverage through a Medicaid state plan option (SPA). Under the SPA option, states must provide full benefits during and throughout the 12-month postpartum period. If a state covers pregnant people through the Children’s Health Insurance Program (CHIP), it must also elect to extend coverage through CHIP. This state plan option is only available for a five-year period starting April 1, 2022.
As described in more detail below, two states – Illinois and Missouri – recently received approval from the Biden Administration for the extension of Medicaid postpartum coverage. Washington State has enacted legislation to extend Medicaid postpartum coverage and will submit a SPA to CMS for this authority. There are another 33 states that have introduced legislation or enacted legislation to seek federal authority to extend Medicaid coverage to 12 months postpartum. Some states are seeking a full coverage extension for all eligible pregnant people, while other states are defining specific eligibility groups, benefit coverage, and length of the extension (i.e., six-months postpartum).
The maternal mortality crisis continues to be a significant challenge across states. More than half of pregnancy-related deaths occur during the postpartum period, or the period following birth, and 12 percent occur after six-weeks postpartum. Black women are three to four times more likely to die from a preventable pregnancy-related complication compared to non-Hispanic white women; women of color also experience higher rates of uninsurance compared to white non-Hispanic women. Lapses in or loss of coverage may exacerbate existing chronic conditions, such as depression and hypertension, which can contribute to poor maternal health outcomes. Churn, or moving between insurance plans or becoming uninsured, can also pose a serious risk to pregnant people by disrupting care and potentially exacerbating existing health conditions. Higher rates of churn and uninsurance among pregnant women are found in states that have not expanded Medicaid under the ACA.
Extending Medicaid postpartum coverage is a key strategy to address maternal mortality and loss of coverage. Currently, Medicaid coverage for pregnant people lasts until 60 days postpartum and individuals are typically disenrolled on the last day of the month. After this period, postpartum people may:
- requalify for Medicaid if they live in a state that has expanded Medicaid and they meet expansion eligibility criteria, including the income requirements,
- requalify for Medicaid if they are a parent with a dependent child and meet eligibility criteria, including the income and age requirements,
- seek private coverage through the individual marketplace, which generally includes premiums and higher out-of-pocket spending compared to Medicaid, or
- become uninsured.
The following describes three states’ efforts to extend postpartum coverage through a Medicaid section 1115 waiver or through a state plan option, as allowed under ARPA.
In May of 2021, CMS approved Illinois’ request to expand full Medicaid coverage from 60 days to 12 months postpartum under a Medicaid Section 1115 demonstration. The goal of this extension of coverage is to reduce health disparities and strengthen continuity of coverage by allowing mothers to stay with their existing providers, prevent gaps in insurance coverage, and provide access to needed care, including behavioral health services and services to manage chronic conditions, such as diabetes and hypertension, during the full postpartum period.
In 2018, Missouri enacted a law allowing the state to seek federal authority to extend Missouri HealthNet (Medicaid) benefits for postpartum women who are diagnosed with a substance use disorder (SUD) within 60 days of giving birth. The state submitted an 1115 Demonstration waiver, which was approved by CMS in March 2021. Women who meet the criteria of the Missouri Targeted Benefits for Pregnant Women Demonstration program will be eligible for SUD treatment, as well as treatment for mental health conditions related to SUD for up to twelve months following delivery. The intent is to improve access to quality treatment for SUD, and mental health conditions related to SUD, for women who recently gave birth. Anticipated results include increased adherence to and retention of SUD treatment plans; reduction in SUD-related hospitalizations and emergency room visits; strengthened safeguards for the health of women and children during the postpartum period and first year of the newborn’s life; and improvement in health outcomes for women and children.
In May 2021, Washington State enacted a law to extend Medicaid postpartum/post-pregnancy coverage to 12 months, with an implementation date of June 2022. The state plans to submit a SPA to CMS, as allowed under ARPA. Under the law, the state will also provide coverage for undocumented individuals who do not qualify for Medicaid coverage but whom are in the window of up to 12 months postpartum. The law will also provide coverage to individuals who had any end of pregnancy outcome.
Promoting continuity of coverage is a critical strategy for addressing the maternal mortality crisis. NASHP expects states to continue pursuing postpartum coverage extensions, particularly through the state plan option under ARPA. For more information on state actions to extend postpartum coverage, visit NASHP’s Extending Postpartum Coverage Tracker, which is updated monthly.